IHI Ventilator Bundle: Daily "Sedation Vacations" and Assessment of Readiness to Extubate

Using daily "sedation vacations" and assessing the patient’s readiness to extubate is an integral part of the IHI Ventilator Bundle and has been correlated with reduction in the rate of ventilator-acquired pneumonia.

 
Kress et al. conducted a randomized controlled trial in 128 adult patients on mechanical ventilation, randomized to daily interruption of sedation irrespective of clinical state or interruption at the clinician’s discretion. Daily interruption resulted in a marked and highly significant reduction in time on mechanical ventilation. The duration of mechanical ventilation decreased from 7.3 days to 4.9 days (p=0.004). [1]
 
It appears that lightening sedation decreases the amount of time spent on mechanical ventilation and therefore the risk of ventilator-acquired pneumonia. In addition, weaning patients from ventilators becomes easier when patients are able to assist themselves at extubation with coughing and control of secretions.
 
Sedation vacations are not without risks, however. Patients who are not sedated as deeply will have an increased potential for self-extubation. Therefore, the maneuver must be conducted in a careful fashion. In addition, there may be an increased potential for pain and anxiety associated with lightening sedation. Lastly, increased tone and poor synchrony with the ventilator during the maneuver may risk episodes of desaturation. 
 
 
References:
  1. Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine. May 18 2000;342(20):1471-1477.

 

 

Tips

  • Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate.  Include precautions to prevent self-extubation such as increased montoring and vigilance during the trial.
  • Include a sedation vacation strategy in your overall plan to wean the patient from the ventilator; if you have a weaning protocol, add "sedation vacation" to that strategy.
  • Assess that compliance is occurring each day on multidisciplinary rounds.
  • Consider implementation of a sedation scale such as the Riker scale to avoid oversedation. 
  • Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

 

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